Provider Demographics
NPI:1053301267
Name:EICHENBAUM, JOSEPH (MDFACC)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:EICHENBAUM
Suffix:
Gender:M
Credentials:MDFACC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-3243
Mailing Address - Country:US
Mailing Address - Phone:516-596-6100
Mailing Address - Fax:516-599-6989
Practice Address - Street 1:253 BROADWAY
Practice Address - Street 2:
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-3243
Practice Address - Country:US
Practice Address - Phone:516-596-6100
Practice Address - Fax:516-599-6989
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY147959174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00883830Medicaid
NY00883830Medicaid
NYB14225Medicare UPIN